SBRT or right to Inhibitor due to recurrence

Portal Forums Cancer Treatments / Symptom Management General Treatments / Symptom Mgmt. SBRT or right to Inhibitor due to recurrence

This topic contains 5 replies, has 5 voices, and was last updated by  Dr. Ben Creelan 2 years, 1 month ago.

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October 7, 2015 at 4:08 am  #1271407    

tuliptime

I have a recurrence of my stage IIIA lung cancer, adeno, ALK+ from 2012. I have a small paraspinal mass outside of the old radiation field that was biopsied and is definitely adeno ALK. I also have a non enlarged lymph node, station 5/6 which was in the radiation field with an SUV of 5 on the PET scan. Mass was 10.

I have two options and need to decide in the next day or two:

Option one: go 5 days of SBRT on the mass then either go right to Xalkori or do a wait and see CT scan in 3 months. Reason being of course inhibitors only work for so long and would try to stretch it as much as possible.

Option two: go straight to Xalkori since hot lymph node is most likely cancer (but all docs say we do not know for sure) and then perhaps do radiation down the road

This mass is causing me lots of pain. However, I suppose I can deal with that as I am taking lots of Gabapentin and can up it. Note my recurrence was overlooked for 1 year on my CT’s. Pretty devasting. I was even told I was clear in April and to come back in a year. I was the one to prompt this investigation. Granted on paper it does not matter now, but it sure does to me.

I know you cannot provide specific medical advice but I am just asking what the protocol or recommendation would be, that’s all.

Thank you and have a nice day.

October 7, 2015 at 10:38 am  #1271413    
catdander forum moderator
catdander forum moderator

Hi tuliptime,

I’m so sorry cancer has reared its ugly head. You’re right about wanting your treatments lasting as long as possible. As Dr. West puts it you want to move through treatments more like a marathon than a sprint. Following are things to keep in mind while deciding on what the best action for you is.

Radiation is used as palliative/when the pain becomes too much. Other reasons to have radiation are when the tumor obstructs airflow or endangers bone stability, etc. There is only so much total radiation a person can have, the use of stereotactic radiation may increase those numbers. Following is a video on reirradiation http://cancergrace.org/lung/2015/09/28/gcvl_lu-e12_lung_cancer_tumor_reirradiation/

Some lung cancers can be extremely slow growing and have the best chance of winning a marathon. Dr. West discusses that here, ” But if you see just a single area growing, perhaps, even if it’s against a background of several other areas of known disease, if all of the other areas are growing at such a slow pace that you really don’t necessarily need to worry about them as a threat any time soon, it might make sense to just get the lead runner, to borrow a term in baseball, and address and neutralize the only area the really seems to be leading the charge as a threat.

“And then, if we do see areas of multifocal progression, multiple areas growing at once, the leading consideration is going to be systemic therapy. If that’s the case, the leading question after that is: what is the best treatment to pursue — and that’s the subject of other videos here.”

http://cancergrace.org/lung/2015/09/14/gcvl_lu-f03_indolent_lung_cancer_management/

If you’re unsure your team is pursuing the right path a 2nd opinion is always appropriate. Dr. Weiss has written an excellent post on the subject, http://cancergrace.org/cancer-101/2011/11/13/an-insider%E2%80%99s-guide-to-the-second-opinion/

Let us know what other questions you have and please keep us posted.

Janine

October 7, 2015 at 11:16 am  #1271415    
JimC Forum Moderator
JimC Forum Moderator

Hi tuliptime,

I’m sorry to hear that a recurrence has been confirmed. As you say, we can’t tell you what should be done, but I’ll share some thoughts on factors that might influence your decision.

Given the pain you’re experiencing from the mass and its SUV, that would suggest that early intervention would be a good idea, and usually the quickest way to alleviate cancer pain is to radiate whatever is causing that pain. Since you’re ALK+, Xalkori might also provide relief fairly quickly, but not all patients respond that rapidly.

As far as whether to hold off on Xalkori, there is the school of thought that if you have a weapon in your arsenal and you have a chance to knock out the remaining cancer, you do it sooner than later. In addition, research continues into later-generation ALK inhibitors, which may be useful if you later need them.

Again, these are just different ways of looking at the situation; there is no right or wrong answer.

Good luck with the treatment path you choose.

JimC
Forum moderator


Jul 2008 Wife Liz (51/never smoker) Dx Stage IV NSCLC EGFR exon 19
4 cycles Carbo/alimta, 65% shrinkage
Tarceva maintenance
Mar 2010 progression, added Alimta, stable
Sep 2010 multiple brain mets, WBR
Oct 2010 large pericardial effusion, tamponade
Jan 2011 progression, start abraxane
Jun 2011-New liver, brain mets, add Tarceva
Oct 2011-Dx Leptomeningeal carcinomatosis; pulsed Tarceva
At rest Nov 4 2011
Since then: http://cancergrace.org/blog/jim-and-lisa

October 8, 2015 at 3:53 pm  #1271425    

Andromeda52

Jim, any chance one of the doctors could weigh in on this post? It’d be great to hear an lung oncologist’s professional opinion or pros & cons of one course of treatment over another.
Thanks,
Gail

October 9, 2015 at 1:42 pm  #1271432    
catdander forum moderator
catdander forum moderator

Will do Gail.

October 12, 2015 at 9:53 am  #1271449    

Dr. Ben Creelan

There is no wrong answer here, either is reasonable.

If the spine mass is truly responsible for the pain, then I would do XRT for that first. Then in 3 months, if there are new lesions or enlargement of existing lesions on plain CT, it would make sense to start the Xalkori.

Personally I prefer to start the drugs like Xalkori when there is clearly objective, measurable tumor, so I can tell if it is working or not. SUV is not as reliable as tumor size in this setting. In this setting, I don’t like exposing patients to side effects unless I am certain that the drug is having an effect.

Option 3: There are also several trials testing the 2nd generation ALK inhibitors, like alectinib, for your situation. Bear in mind though, most of these trials are randomized. If that interests you, then I suggest looking into the trial before you get SBXRT.

https://www.clinicaltrials.gov/ct2/show/NCT02075840?term=alectinib&rank=2

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